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Tier 1 - Health status and outcomes

1.11 Oral health

Key facts

Why is it important?

Oral health refers to the health of tissues of the mouth: muscle, bone, teeth and gums. The two most frequently occurring oral diseases are tooth decay (termed ‘caries’) and gum (periodontal) disease. If not treated in a timely manner, these can cause discomfort and tooth loss, impacting a person's ability to eat, speak, and socialise without discomfort or embarrassment (Williams et al. 2011). Oral diseases can intensify other chronic diseases (Jamieson et al. 2010a) and have been found to be associated with cardiovascular diseases (Ylöstalo et al. 2006), diabetes (Taylor & Borgnakke 2008), stroke (Joshipura et al. 2003) and pre-term low birthweight (Roberts-Thomson et al. 2008; Williams et al. 2011; Xiong et al. 2006).

Aboriginal and Torres Strait Islander children and adults have much higher rates of dental disease than their non-Indigenous counterparts across Australia, which can be largely attributed to the social determinants of health, such as poverty, racism and the consequences of colonialism (Australian Medical Association 2019). Indigenous Australians are more likely than non-Indigenous Australians to have multiple caries, have lost all their teeth, and/or to have gum disease (Jamieson et al. 2010b) and also less likely to receive the dental care that they need (Jamieson et al. 2010a; Kruger & Tennant 2015; Slade et al. 2007).

Tooth decay can be largely prevented by diet (for example reducing intake of processed sugary foods/drinks), fluoridation of water supplies (Lalloo et al. 2015), appropriate use of fluoridated toothpaste, good oral hygiene and regular dental check-ups. The same risk factors apply to periodontal diseases as well as smoking, diabetes, stress, and substance use (particularly inhalant use). Lower levels of education and income and sub-standard living conditions are associated with oral diseases (Lalloo et al. 2016). In addition to oral hygiene and dental care, tooth loss is associated with increased age and accidents and injuries (Jamieson et al. 2010a; Williams et al. 2011).

Burden of disease

In 2011, oral disorders accounted for 1.7% of the total burden of disease among Indigenous Australians. The oral disorders contributing to this burden were dental caries (68%), periodontal disease (17%), severe tooth loss (15%) and other oral disorders (0.2%). The burden due to dental caries was most common among children, periodontal disease was most common among those aged 40–64 and severe tooth loss was most common among those aged 55–64 (AIHW 2016).

Findings

What does the data tell us?

Self-reported survey data

Through the 2018–19 National Aboriginal and Torres Strait Islander Health Survey (Health Survey), 81% of Indigenous Australians reported that they brushed their teeth daily and 45% brushed their teeth twice a day. An estimated 50% of Indigenous Australians had seen a dentist in the last 12 months and 12% had never seen a health professional about teeth.

Of Indigenous Australians who had seen a dentist, 38% visited private dentists, 28% a government dental clinic, 12% a school dentist, and 18% a dentist at an Aboriginal Medical Service. Around half (49%) of Indigenous Australians living in Non-remote areas waited less than one week to see a dentist (Table D1.11.11).

An estimated 19% of Indigenous Australians reported that they didn’t go to a dentist when they needed to in the previous 12 months. Reasons included: cost (42%), too busy (24%), disliking service or professional, or feeling embarrassed or afraid (22%) and waiting time too long or not available at time required (15%) (Table D3.08.3, Figure 1.11.1).

Figure 1.11.1: Indigenous Australians who needed to go to a dentist in the last 12 months but didn't, by reason, 2018–19

This bar chart shows that, the top 3 reasons for Indigenous Australians who needed to go to a dentist but didn't was cost (42%), being too busy (24%) and disliking the service, professional or was embarrassed or afraid (22%).

Source: Table D3.08.3. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19.

In 2018–19, 82% of Indigenous children aged 0–14 were reported to brush their teeth daily, 58% had their last appointment within the previous 12 months, and 23% reported having never seen a dentist.

Of Indigenous children aged 0–14 who had seen a dentist, 30% attended a school dental clinic, 28% attended a private clinic (including specialists), 24% attended a government dental clinic and 14% attended a dentist at an Aboriginal Medical Service. Of Indigenous children living in Remote areas, 38% went to a school dental clinic, compared with 28% of those in Non-remote areas (Table D1.11.29, Figure 1.11.2).

In 2018–19, 3% of Indigenous children aged 0–14 were reported as needing to go to the dentist in the past 12 months but did not. The most common reasons parents attributed this to were: cost (32%); disliked service or professional or felt embarrassed or afraid (17%); too busy (16%); or waiting time or an appointment not available at the time required (13%) (Table D3.08.3).

Figure 1.11.2: Type of dental practice attended by Indigenous children 0–14, by remoteness, 2018–19

This bar chart shows that, in non-remote areas Indigenous children were more likely to attend a private dental clinic (32%) than those in remote areas (8%). Indigenous children in remote areas were more likely to visit a dentist at an Aboriginal Medical Service (26%) as well as a government funded (26%), or school dental clinic (38%) compared to those in non-remote areas (12%, 23% and 28%, respectively).

Source: Table D1.11.29. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19.

Based on self-reported data from the 2014–15 National Aboriginal and Torres Strait Islander Social Survey, 28% of Indigenous children aged under 15 had teeth or gum problems in 2014–15 (Table D1.11.1). The most common types of problems were cavities or dental decay (12%), fillings due to dental decay (11%), needing braces/plate/retainer (6%) and having teeth pulled out due to dental decay (5%) (Table D1.11.3, Figure 1.11.3).

Among Indigenous children with reported teeth or gum problems, 56% experienced the problem for at least 12 months. This was more common for Indigenous children living in Non-remote areas (58%) compared with Remote areas (45%) (Table D1.11.5). Just over 29% of Indigenous children had their last dental check less than 3 months ago, and 8% with reported teeth or gum problems had never been to a dentist (Table D1.11.6).

The largest proportion of Indigenous children with teeth or gum problems was for those aged 10–14 (39%), followed by those aged 5–9 (33%) and 0–4 (11%) (Table D1.11.4).

Figure 1.11.3: Proportion of Indigenous children aged 0–14 with reported teeth or gum problems, by type of dental or gum problem, 2014–15

This bar chart shows that overall, 28% of Indigenous children aged 0 to 14 were reported to have teeth or gum problems. The top 2 problems were cavities or dental decay (12%) and tooth or teeth were filled because of decay (11%).

Source: D1.11.3. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Social Survey 2014–15.

Child Dental Benefits Schedule

In 2015, 45,396 Indigenous children received dental services under the Child Dental Benefits Schedule, representing 20% of those eligible for these services. In comparison, 35% of eligible non-Indigenous children had received these services (Table D1.11.26).

Dental health in the Northern Territory

Between August 2007 and December 2018, 37,005 dental services were provided to 13,786 Indigenous children under the National Partnership Agreement on Northern Territory Remote Aboriginal Investment (NTRAI). Over this period, 86% of Indigenous children who had a dental service had two or more dental checks (Table D1.11.22). Over half (51%) of Indigenous children who received a dental service were aged 6–11 (Table D1.11.23).

Between August 2007 and June 2012, 7,403 Indigenous children received dental services under the Child Health Check Initiative Program and 46% of those children were treated for at least one dental problem. Thirty-eight per cent of Indigenous children who received dental services under the program were treated for untreated tooth decay (Table D1.11.25).

The Stronger Futures in the Northern Territory (SFNT) program began in July 2012 and continues to provide funding through the NTRAI from 2015–16 to 2021–22. The oral health component of this agreement replaced and expanded services implemented under the Northern Territory Emergency Response Child Health Check Initiative and the Closing the Gap in the Northern Territory National Partnership Agreement. The funding was mainly used to enhance oral health services to children aged under 16 in the Northern Territory.

Between July 2012 and December 2018, 13,143 children received 25,419 clinical services. The numbers fluctuated over time but were lower in 2018 than in 2016 or 2017. The proportion of dental service recipients with tooth decay decreased for most age groups between March 2009 and December 2018. The largest decrease was for Indigenous children aged 1–3 combined (from 73% to 41%), followed by those aged 12 years (from 81% to 63%) (AIHW 2019). 

Tooth loss

The 2018–19 Health Survey collected data on tooth loss. This data showed that 6% of Indigenous Australians aged 15 and over were reported to have complete tooth loss, and a further 45% having lost at least one tooth (excluding wisdom teeth) (Table D1.11.7, Figure 1.11.4).

Figure 1.11.4: Status of tooth loss, Indigenous persons 15 years and over, by age, 2018–19

This stacked bar chart shows that overall, 45% of Indigenous Australians over the age of 15 had lost one or more teeth and 6% had complete tooth loss. For people aged 55 and over, 62% had lost one or more teeth, and 25% had complete tooth loss.

Source: Table D1.11.7. AIHW and ABS analysis of National Aboriginal and Torres Strait Islander Health Survey 2018–19.

In 2018–19, rates of complete tooth loss were highest for Indigenous Australians aged 55 and over living in Non-remote areas (26%). This compared to 22% of Indigenous Australians aged 55 and over living in Remote areas (Table D1.11.10).

The proportion of Indigenous Australians with complete tooth loss was higher for those with: three or more long term health conditions (8.6 times those with no conditions); Year 9 or below as the highest year of schooling (8 times those with Year 12); the lowest income (4.9 times those with the highest income); heart or circulatory problems (4.9 times those without heart/circulatory problems); and self-reported diabetes or high blood sugar levels (4 times those without diabetes or HSL) (Table D1.11.8, Table D1.11.9).

Hospitalisation

Between July 2015 and June 2017, Indigenous children aged 0–4 were hospitalised for dental conditions at 1.7 times the rate of non-Indigenous children (6.2 and 3.7 per 1,000, respectively) and those aged 5–14 were hospitalised at 1.3 times the rate (6.1 and 4.6 per 1,000, respectively). Hospitalisation rates of Indigenous Australians for dental problems declined after age 14 (Table D1.11.21, Figure 1.11.5).

Figure 1.11.5: Age-specific hospitalisation rates for a principal diagnosis of dental problems, by Indigenous status and age, Australia, July 2015 to June 2017

This bar chart shows that, for Indigenous and non-Indigenous Australians, hospitalisation rates for a principal diagnosis of dental problems was highest for children aged 0 to 14. In particular, for Indigenous children aged 0 to 4 the rate was 6.2 per 1,000 compared with 3.7 per 1,000 for non-Indigenous children. For those aged 5-14, the rate was 6.1 per 1,000 for Indigenous children compared with 4.6 per 1,000 for non-Indigenous children.

Source: Table D1.11.21. AIHW analysis of National Hospital Morbidity Database.

Data on hospital dental procedures involving general anaesthesia show that the highest rates were for Indigenous children aged 5–9 (12 per 1,000) followed by those aged 0–4 (8 per 1,000). For those aged 10 and over, rates of hospitalisation for dental procedures involving general anaesthesia were lower for Indigenous Australians than non-Indigenous Australians (Table D1.11.28).

Indigenous Australians aged 25–34 (1.7 per 1,000) were 3.5 times as likely to be hospitalised for periodontal disease compared with non-Indigenous Australians (0.5 per 1,000) (Table D1.11.31).

Child Dental Health Survey

In the 2010 Child Dental Health Survey, the average number of decayed, missing or filled deciduous teeth (baby teeth) among Indigenous children aged 5–10 was 1.7 times the number for non-Indigenous children (3.8 and 2.2, respectively) in the six jurisdictions combined with data of adequate quality (Queensland, Western Australia, South Australia, Tasmania, the Australian Capital Territory and the Northern Territory) (Table D1.11.13). Indigenous children aged 5–10 were less likely to have no decayed, missing or filled deciduous teeth (24%) than non-Indigenous children (45%) (Table D1.11.14, Figure 1.11.6).

Figure 1.11.6: Proportion of children aged 5–10 with no decayed, missing or filled deciduous teeth (dmft = 0), by age and Indigenous status, 2010

This bar chart shows that overall, 24% of indigenous children aged 5 to 10 and 45% of non-Indigenous children had no decayed, missing or filled deciduous teeth. For Indigenous children the proportion was lowest for 7 year old children (18%), and highest for 10 year old children (34%).

Source: Table D1.11.14.  AIHW analysis of Child Dental Health Survey 2010.

By age 14–15, Indigenous children had on average, twice as many decayed teeth, 2.8 times the number of missing teeth and 1.4 times the number of filled teeth than non-Indigenous children (Table D1.11.15). For those aged 6–15, 48% of Indigenous children had no decayed, missing or filled permanent teeth compared with 63% of non-Indigenous children (Table D1.11.16, Figure 1.11.7).

Figure 1.11.7: Proportion of children aged 6–15 with no decayed, missing or filled permanent teeth (DMFT = 0), by age and Indigenous status, 2010

This bar chart shows that, for children aged 6 to 15, 48% of Indigenous children and 63% of non-Indigenous children had no decayed, missing or filled permanent teeth. For Indigenous children, the proportion decreased with age from 90% for 6 year olds to 16% for 14 year olds. For non-Indigenous children the proportion decreased with age from 93% for children aged 6 to 35% for those aged 15.

Source: Table D1.11.16. AIHW analysis of Child Dental Health Survey 2010.

What do research and evaluations tell us?

Poor oral health is strongly associated with low socioeconomic status. Research has shown that adults who are socially disadvantaged or on a low income have more than double the rate of poor oral health than those on higher incomes, including higher rates of untreated decay (Brennan et al. 2019).

Western dental approaches (for example fluoride varnish), while clinically efficacious may not be enough to lead to lasting dental improvement in Indigenous Australian children, where other determinants such as socioeconomic status, access to services, and cultural and environmental factors act as barriers to oral health (Patel et al. 2017; Smith et al. 2007; Williams et al. 2011). Community-based interventions for oral health care should build on community strengths and harness local Indigenous Health Workers to work with families and communities in oral health promotion (Slade et al. 2011).

An effective program in Port Augusta, South Australia, highlighted the challenges in achieving this mix of community engagement, health promotion and provision of dental services. The program also faced a number of hurdles with patient attendance, including difficulties with transport, and a lack of understanding of the importance of dental health among Indigenous Australian families (Parker et al. 2012).

In South Australia, the Aboriginal Health Program introduced in 2005 saw an increase of Indigenous Australians accessing mainstream dental care from 60 to 4,800 people by 2014–15. The key strategies of the program include: ensuring Indigenous adults are referred to dental services for free general and emergency dental care with no waiting lists; increasing the number of Indigenous teenagers accessing dental care; ensuring Indigenous children can access dental care from a variety of pathways; working with health professionals and pregnant women to increase their oral health knowledge; and to develop a range of oral health resources for Indigenous Australians (The University of Adelaide 2020).

Development and implementation of evidence based oral health promotion and prevention programs is fundamental to effective provision of appropriate services to meet population oral health needs. Improving the evidence base for oral health promotion programs for Indigenous Australians is necessary (COAG Health Council 2015).

Patel and others (2017) published a review of oral health interventions for Indigenous Australian communities (Patel et al. 2017). The review found oral health interventions should not just be community-based but also community-driven with a shared understanding of outcomes, and mutually reinforcing and coordinated activities including using the skills of local staff and building capacity in oral health promotion. However, the impact of social determinants beyond the delivery of oral health services will continue to limit the effect of oral health interventions on Indigenous health outcomes, and contribute to the disparity between Indigenous and non-Indigenous Australians.

Gwyn and others (2020) published a review of international studies and evaluations of community based oral health interventions targeting indigenous adolescents and found a shortage of good quality evaluations (Gwynn et al. 2020). Studies lacked strong indigenous community engagement, governance or leadership. The review recommended that this must be included in community based oral health interventions and research.

Implications

Available data indicate that dental health is worse for Indigenous Australians than for non-Indigenous Australians, for both children and adults. Barriers to good oral health include cost of services (see measure 3.14 Access to services compared with need) and healthy diets on limited budgets (see measure 2.19 Dietary behaviours). Further barriers include attending services for pain not prevention, insufficient education about oral health and preventing disease, public dental services not meeting demand, lack of fluoridation in some water supplies, and cultural competency issues with some service providers (see measure 3.08 Cultural competency) (Durey et al. 2016; Dyson et al. 2014; Johnson et al. 2014).

Dental health workforce shortages in remote areas need to be addressed with creative solutions beyond financial incentives to improve workforce retention. Stronger representation of Indigenous Australians in the dental health workforce will likely be highly valued by Indigenous patients, and improve the cultural safety of services and hospitals. Regulatory hurdles that affect some dental services (such as fluoride varnish) need to be overcome to improve the flexibility and delivery of effective dental care (Australian Medical Association 2019).

The data also illustrates the importance of school dental programs for many Indigenous Australian children, particularly those living in remote areas. Schools are common settings for oral health interventions internationally as an opportunity for targeting student dental needs. However, they may be underutilised by Indigenous Australian children (Parker et al. 2012). This could mean mainstream school dental services lack cultural safety, but may be filling a service gap in the absence of a more suitable alternative, such as a culturally friendly children’s dental service incorporated into an Aboriginal Community Controlled Health Service.

School-based interventions may crowd out opportunities to deliver oral health promotion to families. Evidence suggests there is a lack of community understanding about the importance of oral health. This understanding could be built through community-driven programs working with dental care providers and with mutually reinforcing and coordinated activities that involve families. However, barriers to sustainable oral health improvements will remain until the broader social determinants and inequities affecting Indigenous Australians are addressed.

Prevalence estimates for oral health conditions for Indigenous Australians are based on incomplete or out-of-date surveys—further data development is a priority for this performance measure.

A more coordinated and consistent approach to research and evaluation will provide the basis for continuous improvement of oral health services and systems.

The policy context is at Policies and strategies.

References

  • AIHW 2016. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Australian Burden of Disease Study series 6. Cat. no. BOD 7. Canberra: AIHW.
  • AIHW 2019. Northern Territory Remote Aboriginal Investment: Oral Health Program July 2012 to December 2018. Canberra: AIHW.
  • Australian Medical Association 2019. 2019 AMA Report card on Indigenous health. No more decay: addressing the oral health needs of Aboriginal and Torres Strait Islander Australians.: Australian Medical Association.
  • Brennan DS, Spencer AJ & Roberts-Thomson KF 2019. Socioeconomic and psychosocial associations with oral health impact and general health. Community Dentistry and Oral Epidemiology 47:32-9.
  • COAG Health Council 2015. Healthy Mouths, Healthy Lives: Australia’s National Oral Health Plan 2015–2024. South Australian Dental Service Adelaide (AUST).
  • Durey A, McAullay D, Gibson B & Slack-Smith L 2016. Aboriginal Health Worker perceptions of oral health: a qualitative study in Perth, Western Australia. International Journal for Equity in Health 15:4.
  • Dyson K, Kruger E & Tennant M 2014. A decade of experience evolving visiting dental services in partnership with rural remote Aboriginal communities. Australian Dental Journal 59:187-92.
  • Gwynn J, Skinner J, Dimitropoulos Y, Masoe A, Rambaldini B, Christie V et al. 2020. Community based programs to improve the oral health of Australian Indigenous adolescents: a systematic review and recommendations to guide future strategies. BMC health services research 20:1-14.
  • Jamieson LM, Roberts-Thomson KF & Sayers SM 2010a. Risk indicators for severe impaired oral health among indigenous Australian young adults. BMC Oral Health 10:1.
  • Jamieson LM, Sayers S & Roberts-Thomson KF 2010b. Clinical oral health outcomes in young Australian Aboriginal adults compared with national-level counterparts. The Medical Journal of Australia 192:558-61.
  • Johnson NW, Lalloo R, Kroon J, Fernando S & Tut O 2014. Effectiveness of water fluoridation in caries reduction in a remote Indigenous community in Far North Queensland. Australian Dental Journal 59:366-71.
  • Joshipura KJ, Hung H-C, Rimm EB, Willett WC & Ascherio A 2003. Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke 34:47-52.
  • Kruger E & Tennant M 2015. Potentially preventable hospital separations related to oral health: a 10-year analysis. Australian Dental Journal 60:205-11.
  • Lalloo R, Jamieson LM, Ha D, Ellershaw A & Luzzi L 2015. Does fluoride in the water close the dental caries gap between Indigenous and non-Indigenous children? Australian Dental Journal 60:390-6.
  • Lalloo R, Jamieson LM, Ha D & Luzzi L 2016. Inequalities in Tooth Decay in Australian Children by Neighbourhood Characteristics and Indigenous Status. Journal of Health Care for the Poor and Underserved 27:161-77.
  • Parker E, Misan G, Shearer M, Richards L, Russell A, Mills H et al. 2012. Planning, implementing, and evaluating a program to address the oral health needs of Aboriginal children in Port Augusta, Australia. International journal of pediatrics 2012.
  • Patel J, Durey A, Hearn L & Slack‐Smith L 2017. Oral health interventions in Australian Aboriginal communities: a review of the literature. Australian Dental Journal 62:283-94.
  • Roberts-Thomson KF, Spencer AJ & Jamieson L 2008. Oral health of Aboriginal and Torres Strait Islander Australians. The Medical Journal of Australia 188:592-3.
  • Slade GD, Bailie RS, Roberts‐Thomson K, Leach AJ, Raye I, Endean C et al. 2011. Effect of health promotion and fluoride varnish on dental caries among Australian Aboriginal children: results from a community‐randomized controlled trial. Community Dentistry and Oral Epidemiology 39:29-43.
  • Slade GD, Spencer A & Roberts-Thomson KF 2007. Australia's Dental Generations: The National Survey of Adult Oral Health, 2004-06. Australian Institute of Health and Welfare.
  • Smith K, Kruger E, Dyson K & Tennant M 2007. Oral health in rural and remote Western Australian Indigenous communities: A two‐year retrospective analysis of 999 people. International Dental Journal 57:93-9.
  • Taylor GW & Borgnakke W 2008. Periodontal disease: associations with diabetes, glycemic control and complications. Oral diseases 14:191-203.
  • The University of Adelaide 2020. Aboriginal Oral Health Program - SA Dental Service.
  • Williams S, Jamieson L, MacRae A & Gray C 2011. Review of Indigenous oral health. Australian Indigenous HealthInfoNet No. 7.
  • Xiong X, Buekens P, Fraser W, Beck J & Offenbacher S 2006. Periodontal disease and adverse pregnancy outcomes: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology 113:135-43.
  • Ylöstalo P, Järvelin M, Laitinen J & Knuuttila M 2006. Gingivitis, dental caries and tooth loss: risk factors for cardiovascular diseases or indicators of elevated health risks. Journal of Clinical Periodontology 33:92-101.

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